Scotland: HIV outbreak among people who inject drugs

Since the end of 2014, Glasgow, Scotland has seen more than 130 diagnosed cases of HIV within the community of “public injectors” – people who inject drugs in public places and who are often experiencing homelessness.

With 400-500 individuals estimated to regularly inject in public places in Glasgow city centre, this rate of HIV diagnoses is dramatically higher than the UK rate for people who inject drugs of 0.85 per cent. Traditionally in the Glasgow are the number of cases thought to be transmitted through injecting drug use is on average 10 new cases per year

Dr Erica Peters, an infectious diseases and general medicine consultant at Queen Elizabeth University Hospital in Glasgow, explains that the outbreak was not caused by just one factor.

“Glasgow has had, and continues to have excellent injecting equipment provision services and opiate replacement services. However we know from hepatitis C that there is ongoing transmission risk despite this,” Erica says.

“It seems that the introduction of HIV into this reasonably closed group has resulted in rapid spread.

“There is also some sexual risk and an increase in intravenous cocaine use in recent years. Primarily the drug of choice is heroin.

“In addition the use of novel psychoactive substance benzodiazepines has possibly resulted in higher risk behaviour. All of these things may have been factors and a single factor has not been identified.”

The factors that caused the outbreak to be sustained are also varied.

“Engagement in health care is historically difficult for these people. Levels of testing have not been particularly high.

“Difficulties around accommodation and ongoing mental health and addiction problems continue to be priorities.

“We are aware that sharing and sexual risk persists,” Erica explains.

The Scottish health authorities have undertaken a number of initiatives to help curtail the outbreak:

Ensured that harm reduction and in particular injecting equipment provision services are robust.

Introduced a new “low dead space needle” to reduce any residual blood even if sharing does occur.

Made foils available to encourage movement away from intravenous use.

Linked HIV drugs to opioid replacement therapy prescriptions through community pharmacies. This means if you go in for your methadone you will also get your HIV treatment. Previously people with HIV had to attend a hospital to get treated and also get their medication.

Increased testing within addiction medicine services and the prison sector. “We recommend three-monthly testing in those from Glasgow city centre who have been injecting,” Erica says.

Introduced a pilot project using incentivised testing in a drug crisis centre and a community pharmacy with shopping vouchers available if a person tests.

Erica reports that there are also new HIV clinics in the homeless addiction centre, geographically close to our patients, with appointments available as well as “drop in” services.

“There are two consultants and this means sexual health including contraception, hepatitis C, skin and soft tissue infections can all be treated at the same time. There is a nurse-led clinic and they can facilitate hepatitis C treatment as well.

“We also have sexual health nurses that do partner notification in addition to clinical support.

“Most importantly we have nurses on doing outreach on the street. They have developed strong links with the homeless third sector organisations in addition to other health and social partnerships involved with this group.

“They support patients and work closely with all the agencies and consultants. Without their work we would not have been as successful in getting patients treated.”

The results are looking positive.

“At present we have 77 per cent [of people from this group] on effective treatment with an undetectable viral load, but 94 per cent are currently receiving treatment. Some people have not had on treatment bloods done so the effective number may well be an underestimate. This is all in line with our ‘treatment as prevention’ strategy,” says Erica.

So what lessons are there for Australia in general, and for NSP workers in particular?

“The biggest lesson for us was that this could happen despite very good harm reduction and opiate replacement programs. We were not expecting this.

“Like Australia, we have had a big push on hepatitis C case finding and we thought our blood-borne virus testing was reasonably good.

“We have found that less testing was happening than we thought, and probably those with the biggest risk were the ones that weren’t tested for a variety of reasons,” Erica says.

“I think surveillance for BBV in this population needs to be ongoing. We should realise that risk behaviour continues despite high quality harm reduction and we shouldn’t forget sexual risk.”

“However we have shown that even in this very vulnerable group treatment can happen effectively. It does need a rapid and robust response with significant investment in staffing and multiple agencies working together to support these individuals.”